Diarrhoeal Diseases in Children

Diarrhoeal Diseases in Children

• Diarrhoeal diseases are the second leading cause of death in children under five years old
• Diarrhoeal diseases are preventable and treatable
• Diarrhoea kills around 525,000 children under five each year
• The prevention of diarrhoeal diseases involves safe drinking water, adequate sanitation, and generally good hygiene
• There are nearly 1.7 billion cases of childhood diarrhoeal disease every year, globally
• Diarrhoea is a leading cause of malnutrition in children under the age of five
• Infection is a common cause of acute diarrhea
• Noninfectious etiologies are more common as diarrhoea becomes chronic

Definition of Diarrhoea

• Diarrhoea is when a person passes 3 or more loose or liquid stools per day
• Diarrhoea is defined as more frequent passage than is normal for the individual
• The frequent passing of formed stools isn't diarrhoea
• The passing of loose, "pasty" stools by breastfed babies is not diarrhoea
• The clinical types of diarrhoea include acute, persistent, and chronic

Acute Diarrhoea

• Acute diarrhoea is the sudden onset of typically 3 or more loose or watery stools a day
• Acute diarrhoea persists for 14 days or less
• Acute diarrhoea is is the most frequent gastrointestinal disorder
• Acute diarrhoea the main cause of dehydration in childhood
• The onset of acute diarrhea is often accompanied by anorexia, vomiting, abdominal pain, and elevated body temperature
• Acute diarrhea primarily occurs in children aged 5 years and below, especially in the second half-year of life
• The highest incidence of acute diarrhea is recorded in developing countries
• The most frequent cause of acute diarrhea are gastrointestinal infections
• Infections can be viral, bacterial, or rarely parasitic
• Acute infections spread by fecal-oral transmission
• Rotavirus, norovirus, and Shigella are highly contagious
• Viral causes of acute diarrhea can sometimes be airborne
• The prevalence of specific intestinal pathogens depends on age and the environment of the child
• Alimentary intoxications and wide-spectrum antibiotics contribute to acute diarrhoea

Pathogenesis of Diarrhoea

• Infectious diarrheal disorders are classified into secretory, osmotic-secretory, and exudative-secretory
• Secretory infectious disorders are classified as: V cholera and Toxigenic EC
  • The result is liquid stools
• Osmotic-secretory infectious disorders are classified as Viruses
  • The result is aqueous-mucilaginous stools
• Exudative-secretory infectious disorders are classified as: entero-invasive bacteria like Salmonella, Shigella, Campylobacter, & E. hystolytica
  • The result is blood-stained stools
• Giardia lamblia and Cryptosporidium adhere to the mucosal surface of the proximal small bowel
• Giardia lamblia and Cryptosporidium adheres and causes malabsorptive diarrhoea

Persistent Diarrhoea

• Risk factors include severe acute malnutrition, carbohydrate malabsorption, very young age, and previous infections
• The introduction of animal milk, irrational usage of antibiotics, and lack of breastfeeding are also risk factors
• Pathogenesis involves chronic inflammation and defective intestinal repair
• Defective intestinal repair leads to abnormal mucosal morphology and poor absorption of luminal nutrients
• Defective intestinal repair also increases permeability of the bowel to dietary or microbial antigens
• Severity is greater in younger children due to delayed intestinal mucosal maturation
• Micronutrient deficiencies may prolong mucosal injury so Zinc deficiency may delay intestinal repair mechanisms

Stool Features

• Small bowel related diarrhoea is watery, large volume, and increased frequency
• Small bowel related diarrhoea may involve blood that could be present but usually not gross
• The pH is less than 5.5 and reducing substances are usually positive
• Large bowel related diarrhoea is mucoid/bloody, small volume and excessively increased frequency
• It is also usually grossly bloody, has a pH more than 5.5 and reducing substances are usually negative
• If there are less than 5 white blood cells visible under high power, the white blood cells usually present in the serum appear normal
• Pathogens related to less than 5 white blood cells includes Rotavirus, Adenovirus, Calicivirus, Astrovirus, Norovirus, E coli, Klebsiella, Clostridium perfringens, Cholera species, Vibrio species, Giardia species snd Cryptosporidium species
• If there are more than 10 white blood cells visible under high power, the white blood cells usually present in the serum show leucocytosis
• Pathogens related to more than 10 white blood cells are Escherichia Coli (enteroinvasive, enterohemorrhagic), Shigella species, Salmonella species, Campylobacter species, Yersinia species, Aeromonas species, Plesiomonas species, Clostridium difficile and Entamoeba organisms

Signs and Symptoms

• A careful feeding history is essential in the management of a child with diarrhoea
• Inquire about:
  • Duration
  • Stool frequency
  • Stool consistency
  • Blood in stool
  • Mucus in stools
• Assess the state of dehydration and look for signs of shock
• Severity includes severe, moderate or mild dehydration
• Check presence of blood in the stool and signs of severe malnutrition
• Assess for abdominal mass and intermittent abdominal cramps or intussusception
• Check for abdominal distention and the frequency of bowel sounds
• Routine stool cultures are not needed

Classification of Dehydration

• Signs of severe dehydration are lethargy, unconsciousness, sunken eyes, the inability to drink or drinking poorly, and skin pinching goes back very slowly
• Signs of some dehydration are being restless and irritable, sunken eyes, drinking eagerly, and the skin pinching retracts back slowly

Investigations

• Assess serum electrolytes, particularly Na+ and bicarbonate, in any child considered significantly dehydrated.
• Knowing the serum Na+ concentration is crucial when determining composition of the fluids and rate of rehydration to be used in a child who is dehydrated.
• Perform CBC with differential
• Anemia and thrombocytopenia may be associated with IBD,hemolytic uremic syndrome, malabsorption, tumor, or HIV infection.
• Check for ESR, C-reactive protein; both are elevated in IBD and systemic infections.
• Assess serum blood sugar and arterial blood gases for metabolic acidosis
• Measure renal function with tests for U&Cr plus BUN

Stool Analysis

• Perform occult blood and Leukocytes testing
• Occult blood suggests inflammation, ischemia, tumor, or various infections
• Fecal leukocytes have a high positive predictive value for bacterial diarrhea
• Cultures are for history involving blood, possible travel and if stool exam suggests bacterial cause
• The stool exams should determine:
  • Bacteria
  • If > 5 fecal leukocytes per high power field
  • If diarrhea is prolonged
• Check for Ova and parasites, especially for G lamblia or Cryptosporidium
• Suspect G lamblia or Cryptosporidium especially (e.g., day-care setting)
• Assess pH and reducing substances if presence of reducing substances and low pH suspects malabsorption
• Perform a Fecal fat test performed via a collection of stool for 24-72 hours

Specific Treatment

• Giardiasis: Metronidazole 15mg/kg/dose every 8 hours (q8hr) for 5 days

• Amoebiasis: Metronidazole 35-50 mg/kg/dose q8hr for 10 days

• Shigella: Ciprofloxacin 15mg/kg/dose q12hr or trimethoprim/sulphamethoxazoleor Nalidixic acid 60 mg/kg

• Yersinia: Septrin q12hr or Chloramphenicol 25mg/kg/dose q8hr

• Campylobacter: Erythromycin 10mg/kg/dose q6hr or Septrin or Ciprofloxacin

• E. Coli: Septrin

• Salmonella: IV Ceftriaxone 50mg/kg/dose twice daily, Ciprofloxacin if moderate. May need treatment for 14 days

• Antibiotics are mainly used to address acute gastroenteritis/diarrhea with viral etiology;

  • Avoid antibiotics unless treating a specific bacterial or protozoal cause.

• Anti-emetics, Loperamide and other antispasmodics are generally contraindicated in children.

Complications for Diarrhoea

• Dehydration should be addressed irrespective of any other complication.
• Potassium depletion can be prevented by giving ORS solution or potassium-rich foods such as bananas, coconut water or dark-green leafy vegetables.
• A high fever indicates to possible severe bacterial infection
• Gently push back the the rectal prolapse using a surgical glove or a wet cloth
• Signs of Hemolytic uremic syndrome includes easy bruising, pallor, altered consciousness and low or no urine output
• Signs of Toxic megacolon are fever, abdominal distension, pain and tenderness with loss of bowel sounds, tachycardia and dehydration
• Metabolic Acidosis may occur, alongside malnutrition in recurrent or prolonged diarrhea